From Navigation to Transition Coordination Jo Anne Fante-Gallagher BSN, MHA, RN, CPHQ April 25, 2015

Heart & Vascular Service Line Patient Zero 2012

Heart & Vascular Service Line Clinical Practices of the University of Pennsylvania (CPUP) PENN Medicine Pennsylvania Hospital (PAH) Clinical Care Associates (CCA) Penn Home Care and Hospice Services (PHC&HS) Health System Clinical Components School of Medicine Academic & Research Clinical Hospital of the University of PA (HUP) PENN Presbyterian Medical Center (PPMC) The Chester County Hospital (TCCH) Penn Rittenhouse (in partnership with Good Sheppard Penn Partners) Penn Medicine is committed to remain a world-leading institution in three equally valued and inter-related missions of patient care, education, and research. The success of these missions requires the integration of the School of Medicine and Health Services and a shared destiny with the University of Pennsylvania.

Heart & Vascular Service Line PENN Medicine Heart & Vascular Physician Stats  Physicians  Cardiologists – 160 (clinical and research physicians)  Cardiac Surgeons – 19 (inc. affiliate hospital programs & research physicians)  Vascular Surgeons - 9  Outpatient Clinical Visits  20+ physician practice sites  150,000 total outpatient visits  20,000 new patient visits  Procedures  8,476 cath lab cases (total inpatient/outpatient, diagnostic and interventional)  4,610 EPS cases (total all cases)  2,416 open heart cases  1,900 vascular surgery cases Source: FY13 UPHS Key Indicator Report, and CPUP Analysis FY13 Dec YTD annualized

Heart & Vascular Service Line Where We Were…2012 The current process of communication and care coordination resulted in patient and family dissatisfaction with their Cardiac Surgery experience…and we knew we could do better!  Percentile Rank 20% for HCAHPS MD Communication FY13 73% “Always”  Percentile Rank 54% for HCAHPS RN Communication FY13 78% “Always”  30 Day All Cause Unplanned Cardiac Surgery Readmission Rate at 11%

Heart & Vascular Service Line The need for patient center care coordination became even more apparent.. Patients with one or more chronic health conditions can expect an exponential increase in the number of doctor visits they have a year. Based on Medicare claims data of 2009 and Advisory Board’s research and analysis One Chronic Condition Five or More Chronic Conditions Source: 2009 Medicare Physician Claims; Advisory Board Research and Analysis. 1)Percentages do not add to 100 due to removal of other specialties. The Status Quo Was No Longer Good Enough!

Heart & Vascular Service Line A Shift On Payment Had Begun The shift in the healthcare landscape has set the stakes high & the expectation clear to produce high quality patient centered outcomes through penalty and incentive programs  CMS started it’s penalty program, Value Based Purchasing  The first Hospital Value Based Performance period began July 1, 2011, and ended March 31,  Blue Cross continued its Pay for Performance and continued to raise the stakes on potentially preventable readmissions and inpatient satisfaction.  Increased transparency with public reported outcomes on Hospital Compare websites

Heart & Vascular Service Line The Idea! Cardiac Surgery: Nurse Navigator

Heart & Vascular Service Line Innovative Information Gathering…. Observed Out Patient Appointments Interviewed Out Patient NPs Interviewed and Surveyed Patients & Families at each step in the process including post discharge

Heart & Vascular Service Line “Patient Zero” guided the effort toward a deeper understanding of why patients were returning which lead to beginning of classifying the High Risk Patient Highlighted gaps in the process Interdisciplinary readmission reviews Standardize d tracer tool Rapid cycle iterative changes in the post dc follow up call Capture discreet data

Heart & Vascular Service Line Phase 1 : Identifying What Was Happening Readmission Data FY13 Q CSU patients readmitted –19-calls not made –27-calls made  10 WNL  10 Care Mgt  4 Med Mgt  3 Failed to Serve/Break in Service Post charge calls –Average time per call 15 min (min 2 max 40 ) Was “The Call” Enough?

Heart & Vascular Service Line Phase 2: Finding The Missing Pieces Formalizing The Care Coordination –Average time spent coordinating 30 min (min 15 max 45 ) Finding providers Making appointment  30 New Cardiology referrals  Penn- 17  Non Penn- 13  8 New PCP referrals  Penn- 5  Non Penn- 3  19 Translation services  Translated discharge documents

Heart & Vascular Service Line Are you weighing yourself daily? 347 Do you have a scale at home? 372 Do you have questions about your medications? 367 Has post op visit been scheduled? 378 Has the nurse visited yet? 335 Postop equipment/services: 193 Postop Findings: 372 Was there any equipment/services you were to receive post hospitalization? 355 Were you referred for home care? 374 What was the Outcome of First Attempt? 324 What was the Outcome of Fourth Attempt? 2 What was the Outcome of the Second Attempt? 44 What was the Outcome of Third Attempt? 5 Phase 3: Measuring The Connection Did what we want to happen…actually happen? Was it the right thing for that patient?

Heart & Vascular Service Line Phase 4: Measuring The Volume Of Work Is this work sustainable for one person ?

Heart & Vascular Service Line The Outcome: Identifying Patients At Risk Criteria for being designated high risk: Patients New to Anticoagulation Therapy Patients with Heart Failure TAVR patient Population Those patients with out medical providers

Heart & Vascular Service Line “What information was most important?”

Heart & Vascular Service Line

The Spread of an Idea Navigation branched into 4 main categories that intertwined itself into the patient’s cardiac surgery experience and bridging the gaps to those at risk.

Heart & Vascular Service Line The Call to “Hardwire” the Work

Heart & Vascular Service Line Heart Vascular Service Aligned By Disease To Deliver Seamless Care Consultat ive Cardiolo gy & Network Strategy Heart Failure Valve Arrhyth mia CADVascular Congenit al Quality Leadership OperationsGrowth Clinical Registries & Data Bases The Work Of The Future

Heart & Vascular Service Line Additional Ideas to Enhanced Transitions That Paint the Picture of the Future Innovation reducing readmissions related to anticoagulation  POC testing for valves Measuring what matters  Revenue generated by patients without care providers  Patient impact Expectations set for patients prior to their cardiac surgery experience  Health literate focus on patient education and preoperative prep class  Module information : having what you need when you need it Work that is Innovative, sets clear expectations and adds value to out patients and the health system

Heart & Vascular Service Line Understanding Patient Zero

Heart & Vascular Service Line Impact On So Many 2000 Patient Connections & Counting…

Heart & Vascular Service Line

Patient Satisfaction Data